client's arthritis. Additionally, the healthcare provider has prescribed a low dose aspirin. The client is concerned and asks if it would be acceptable to substitute acetaminophen (Tylenol) instead. What is the nurse's best response?

The Tylenol may cause liver damage and the aspirin will not. I don't recommend substituting it.

Tylenol is a different category of medication to relieve pain so it may not be as effective as aspirin.

Either aspirin or Tylenol will enhance the pain relief of the celecoxib. It would be acceptable if you are more comfortable with it.

The healthcare provider has prescribed aspirin to prevent cardiac complications that may occur with celecoxib. It would not be a good idea to substitute.

Answer and Explanation

The Correct Answer is D

A. The Tylenol may cause liver damage and the aspirin will not. I don't recommend substituting it: While acetaminophen is hepatotoxic in high doses, this does not address the specific pharmacological reason for the aspirin prescription. Aspirin itself carries risks, such as gastrointestinal bleeding and ototoxicity. The comparison of organ toxicity is not the clinical priority in this context.

B. Tylenol is a different category of medication to relieve pain so it may not be as effective as aspirin: Acetaminophen and low-dose aspirin are both used for mild pain, but their analgesic efficacy is not the reason for this combination. The client is being treated for a specific cardiovascular risk associated with selective COX-2 inhibitors. Pain relief is secondary to the antiplatelet goal.

C. Either aspirin or Tylenol will enhance the pain relief of the celecoxib. It would be acceptable if you are more comfortable with it: This response is incorrect and potentially dangerous because it ignores the prophylactic intent of the aspirin. Acetaminophen lacks the antiplatelet properties required to mitigate the pro-thrombotic risks of celecoxib. Encouraging a substitution would leave the client vulnerable to cardiovascular events.

D. The healthcare provider has prescribed aspirin to prevent cardiac complications that may occur with celecoxib. It would not be a good idea to substitute: Celecoxib is associated with an increased risk of myocardial infarction and stroke due to an imbalance in prostacyclin and thromboxane. Low-dose aspirin provides essential antiplatelet therapy to counteract this risk. Acetaminophen cannot provide this specific cardioprotective benefit.

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Correct Answer is B

Explanation

A. Unstageable injury: This classification applies when the true depth of tissue damage is obscured by slough or eschar. The presence of visible, intact skin with erythema allows for a definitive assessment. Because the wound bed is not covered by necrotic debris, this category is clinically inapplicable.

B. Stage 1 pressure injury: This stage is characterized by localized, non-blanchable redness over a bony prominence like the trochanter. The skin remains intact, though the area may be painful or different in temperature. It represents the earliest detectable stage of pressure-induced tissue ischemia and compromise.

C. Stage 2 pressure injury: This injury involves partial-thickness loss of the dermis, appearing as a shallow open ulcer or a serum-filled blister. The question specifies that the skin remains intact, which rules out any epidermal or dermal loss. It lacks the characteristic pink or red moist wound bed.

D. Deep tissue pressure injury (DTI): This manifests as persistent non-blanchable deep red, maroon, or purple discoloration, often feeling mushy or boggy. While it involves intact skin, the specific description of erythema fits a Stage 1 injury better. DTI suggests deeper underlying damage than simple superficial redness.

A. Hemorrhage B. Wound infection C. Wound dehiscence D. Fistula development

Correct Answer is B

Explanation

A. Hemorrhage: This complication involves acute, profuse blood loss from damaged vascular structures within the surgical site. Clinical manifestations typically include hematoma formation, hypovolemia, or bright red sanguineous output. The presence of intact edges and serosanguinous fluid contradicts active arterial or venous bleeding.

B. Wound infection: Pathogenic colonization triggers an inflammatory response characterized by localized erythema and edema around the incision. Increased serosanguinous or purulent exudate reflects the body's immunological reaction to microbial invasion. These clinical markers are classic precursors to localized sepsis or abscess formation.

C. Wound dehiscence: This mechanical failure involves the partial or total separation of previously approximated wound layers. While serosanguinous drainage can precede this event, the question specifically states the incision edges remain intact. Therefore, the structural integrity of the wound has not yet been compromised.

D. Fistula development: This represents the formation of an abnormal passage between two internal organs or an organ and the skin. It usually results from chronic inflammation, malignancy, or severe infection rather than acute post-operative edema. The localized symptoms described are more indicative of a superficial or deep infection.

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client's arthritis. Additionally, the healthcare provider has prescribed a low dose aspirin. The client is concerned and asks if it would be acceptable to substitute acetaminophen (Tylenol) instead. What is the nurse's best response?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for an immobile client and identifies these findings: Painful, persistent non-blanchable erythema at site of right greater trochanter. Skin remains intact. How would the nurse identify these findings in documentation?

Correct Answer is B

Explanation

The nurse is caring for a client with a surgical incision and identifies the following assessments: Incision edges are intact. The area around incision is red and edematous. An increase in serosanguinous drainage is noted from yesterday. Which complication does the nurse anticipate is occurring?

Correct Answer is B

Explanation

The nurse is caring for a postoperative client who is receiving opioid medication for pain management. The nurse notes that the client is more difficult to awaken and has a respiratory rate of 9 breaths per minute. Which medication would the nurse anticipate being given to this client?

If a medication remains in the body of an elderly client for a longer period of time resulting in a longer half-life of the medication, what dosage adjustment would the nurse anticipate to be prescribed?

The nurse questions the wound care specialist about the meaning of an un-stageable pressure injury. Which statement about this condition is correct?

A nurse is reviewing documentation describing a client's wound of right foot and heel. Which of the noted assessments indicate to the nurse that there is a problem with wound healing? (Select All That Apply)

The nurse is performing a health assessment with a 74-year-old client. When questioned about sleep habits, the client says, "I used to sleep like a baby but for the last few years, I seem to be a very light sleeper. Why would this be?" What would be the nurse's best response?

While inspecting a pressure injury on an elderly client, the nurse observes new tissue growth around the area, which is pinkish red in color. How would the nurse identify this area in documentation?